Background

Tumors of the hand are found to be benign 95% of the time in the course of excluding a cutaneous malignancy.
[1] Representing about 60% of these benign tumors is the ganglion cyst.
[2] Although no definitive etiology has been established, the theory that the ganglion is the degeneration of the mucoid connective tissue, specifically collagen, has dominated since 1893, when Ledderhose described it as such.
[3]

The problems that ganglion cysts present can be varied and are due to their location. Most often, the cyst will present at the dorsal wrist, accounting for 60-70% of all hand and wrist ganglia,
[4] and arise from the scapholunate joint.
[5] A ganglion cyst can also arise from the radioscaphoid or scaphotrapezial joint volarly.
[5, 6] These locations can cause joint instability, weakness, and limitation of motion.
[5]

Compression of the median nerve can occur when a volar radial ganglion arises within the carpal canal.
[5] The ulnar nerve may also be compressed within the tunnel of Guyon when the ganglion presents on the ulnar side of the wrist.
[7] The patient can experience paresthesias and pain from a ganglion cyst, and in such cases, surgical treatment should be considered, to provide a favorable outcome with few complications.

Multiple nonsurgical modalities have been used over the years for ganglion cyst, including simple aspiration. Surgery (open or arthroscopic) often becomes necessary, and current evidence suggests that arthroscopic ganglion excision is a practical and successful means of dorsal ganglion cyst removal.
[4, 8, 9, 10]

Pharmacologic agents are under constant investigation in the medical arena. Potential advances in sclerosing agents specific to the treatment of ganglion cysts may lead to a definitive medical treatment of ganglions, which would avoid surgery.

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Anatomy

Dorsal ganglia most often affect the scapholunate joint, and the scaphoid interosseus ligament and extensor tendons must be considered because they are closely associated with the joint capsule. Volar ganglia are commonly associated with the radioscaphoid and scaphotrapezial joints, with proximity to the palmar cutaneous branch of the median nerve and the median nerve itself. Mucous cysts can be anatomically associated with the germinal matrix and are generally displaced lateral to the midline by the extensor tendon.
[2]

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Pathophysiology

Although ganglion cysts can be unilobulated, they are most often multilobulated, with septa made from connective tissue separating the lobes or cavities.
[3] Thornburg points out that because there is no epithelial lining of the cyst wall, a ganglion cyst is not a true cyst and, because of this histologic observation, the theories of synovial herniation or synovial tumor formation are not supported and may be disputed.
[2]

Hyaluronic acid predominates the mucopolysaccharides that make up the fluid within the cyst’s cavity, whereas collagen fibers and fibrocytes make up the wall lining.
[3] The development of these cysts is histologically observable beginning with swollen collagen fibers and fibrocytes, followed by a degeneration and liquefaction of these elements, a termination of degeneration, and, lastly, a proliferation of the connective tissue, resulting in a border that is dense in texture.
[3]

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Etiology

The etiology of the ganglion cyst has been described as an outpouching of synovium; as an irritation of articular tissue, creating a new formation; and, the most common and accepted theory, as a degeneration of connective tissue and cystic space formation.
[3] It has also been suggested that degeneration of the connective tissue is caused by an irritation or chronic damage causing the mesenchymal cells or fibroblasts to produce mucin.
[2]

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Epidemiology

Ganglion cysts are the most common soft-tissue tumors of the hand and wrist. Although anyone can be affected by ganglion cysts, they occur three times as often in women as they do in men. Mucous cysts are found in the distal interphalangeal (DIP) joint and generally present with osteoarthritis, and therefore, they are most commonly seen in older patients. Ganglion cysts are predominantly seen in young adults and are rare in children.
[2]

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Prognosis

Regardless of treatment, recurrence is possible, but the cause is unclear.

Rizzo et al performed a study of arthroscopic excision of dorsal wrist ganglia and found statistically significant increases in wrist extension and grip strength postoperatively, as compared to preoperative values.
[10] Of the 41 patients in the study, 34 had no pain postoperatively, and seven had mild or occasional pain. Only two patients experienced recurrence, but the ganglia recurred again following a second removal using open excision, suggesting that the arthroscopic technique may not have been the cause of failure. Although some patients reported wrist stiffness after the surgery, motion was fully restored by 6 months for the last patient.

Edwards and Johansen prospectively evaluated outcomes of arthroscopic dorsal wrist ganglia resection and found that the patients experienced significant increased function and decreased pain within 6 weeks after arthroscopic resection; recurrence and complication rates appeared comparable to those of open resections.
[8] Ganglion cysts also had a high association with certain interosseous laxities, and recurrent cysts originating from the midcarpal joint were not contraindications for arthroscopic resection. The authors noted that assessment of the midcarpal joint is necessary for complete resection of most ganglion cysts, and identification of a discrete stalk is an uncommon finding and is not necessary for successful resection.

Rocchi et al compared two forms of treatment of volar wrist ganglia: open excision via longitudinal volar skin incision and arthroscopic resection through two or three dorsal ports.
[9] The results of the study suggested that arthroscopic resection is a reasonable alternative to open excision in treating radiocarpal volar ganglia, because it is associated with less postoperative morbidity and a better cosmetic result. Midcarpal volar ganglia, however, according to the authors, should still be treated by open removal.